mHealth in the NHS – Everywhere and Nowhere

If you follow the mHealth blogs and groups on LinkedIn you’ll see a constant debate about where mHealth is in out existing health services.  I’ve been looking at some of the applications which are already in use within the NHS.  As yet, there’s no central policy for mHealth, and it’s debatable whether much of the good practice using mHealth is even acknowledged, but that doesn’t mean it’s not providing benefit. 

Much of mHealth is invisible.  It’s not the high tech monitoring that we find in glossy medical device brochures, but far simpler, everyday applications.   Many of these use SMS, but mHealth extends through voice and video, and we’re already seeing local use of applications on iPhones and Android.  However, there is little coordination of deployment, and almost all that is happening is as a result of local initiatives. 

Let’s look at some of the examples.  Where better to start than midwifery – at the start of life itself?  Portsmouth NHS Trust has produced an excellent example of the benefits from giving staff access to patient’s medical records whilst they’re on the move.  The system uses a digital pen which the midwives use to write up case notes in a preformatted notebook when they visit the pregnant mothers-to-be.  The data from the pen is sent to their Blackberry using a Bluetooth link, and is then transmitted back to the hospital. The information is automatically entered into the patient’s notebook, providing a record of the pregnancy.

The system can alert the hospital staff to any problems in real time.  The application was developed by the trust, with input from physicians to help develop the notebook.  What brought it to life was when the project leader saw a digital pen being used and realised that it could transform the application.  He demonstrated the possibility to hospital staff and it was the midwives who stood up to express interest in trialling it.  Like most of the successful implementations of mobile health projects, they were closely involved in designing how it worked.  The result is that it follows established practices, but makes them much more efficient.  It’s claimed to be a “wild success” amongst the 130 midwives who are using it.  It cost the trust around £150,000 to develop and they believe it has already saved them over £220,000.

The Portsmouth example is an interesting one as most people would consider digital pens to be quite high tech.  One of the reasons that it’s done so well is that the technology “just works” – it’s not changing the way that the midwives work – it’s just letting them do the job more efficiently.  That’s an important message for anyone rolling out an application – those using it need to be able to see that it helps them.  And the best way to achieve that is to involve them in its design.  If users see the benefits, they’ll be enthusiastic about taking it up.

The same applies for applications that are directed at patients.  That’s why there has been spectacular success with SMS.  At the most basic level, SMS is being widely used for appointment reminders.  All sorts of claims have been made for how much this is saving the NHS, and I took a rather light-heated look at this is a previous blog.  Not as much is being written about what it’s doing to improve patient’s lives.  People miss appointments for all sorts of reasons.  Some because they start feeling better and don’t remember to cancel, others because they forget, some because they’re worried about what the diagnosis might be, and some because the condition has worsened and prevented them attending.  Reminders work for all of these, whether it’s just by clearing the appointment for another patient, or helping to ensure that they attend.  The latter is important, as delayed diagnosis can make it more difficult and expensive to provide a cure, adding cost to the subsequent treatment.  SMS reminders can help by catch a disease earlier and using ensuring patients don’t delay or prevaricate in being seen.

Where SMS really comes into its own is where it plays to the privacy and personal nature of a mobile phone.  Companies like iPlato have been instrumental in using this to assist a large range of trials sending personal medical notifications.  Last month Tower Hamlets started sending SMS invites to women in the borough to attend cervical screening sessions at their local GP surgery.  Estimates of the number of deaths in the UK from cervical cancer that could be prevented range from 900 to over 4,000 each year.  Providing personal messages is an effective way to get women into their GP surgery to reduce that number.

A similar strategy is being used by Sandwell Primary Care Trust to remind parents of under fives to take them to attend immunisation clinics.  The MMS saga has left the UK with an unfortunate legacy of low immunisation rates and services like this can help to redress that.

The point to emphasise about SMS is that people respond to messages that arrive on their phone.  They’re seen as personal, so they’re more likely to act upon them.  Having a text on a phone is much more immediate for most people than a letter that drops onto the doormat.  A good example of that was a campaign carried out by the Heart of Birmingham Primary Care Trust earlier this year.  They recruited 24 GP surgeries to send out messages promoting health checks to a target audience of 40 to 74 year olds for whom they had mobile numbers.  That’s not the demographic that’s normally associated with testing, but over 1,850 patients responded, representing a staggering 44% response rate.  The lesson is that if it’s well constructed and targeted, patients respond to messages on their phones.

iPhone and Android apps stores may have several thousand health apps available, but as yet there’s little integration of any of these into the NHS.  They’re certainly being used by patients, and a growing number of GPs and consultants are suggesting them to patients who might find them helpful for managing long term chronic conditions.  The Wilmslow Health centre’s web site is a good, albeit slightly confused example, listing useful apps for their patients. One NHS trust in Bristol went further and jumped on the bandwagon by developing an iPhone application which gave users information on their local health services and provided a rudimentary electronic health record.  That probably won’t save the NHS single-handedly, but anything that makes people more aware of their health has to be a good thing.

There’s fewer cases of remote monitoring using mobile phones, but that’s likely to change in the next twelve months.  The medical device market is at a point of inflection, where it’s moving from proprietary interfaces to standardised wireless connections, based around Bluetooth and Continua standards.  That is going to have two effects.  It will be much easier to connect devices to phones and thence to medical records, and the resulting competition will bring prices down, turning some of these into consumer High Street products.  Once that happens I’m expecting to see rapid evolution in mHealth applications as consumers become capable of monitoring their weight, heart rate and glucose levels and automatically storing the results on a personal health record.  What will be interesting is to see whether this results in patients sharing data with the NHS, keeping it on their own web record, or sharing it more widely with others who have the same condition.

mHealth also extends to remote consultation, of which the most popular example is the service offered by 3G Doctor, allowing patients to contact a GP when and where suits them.  The advantage of this particular service is the way that it integrates with the NHS.

I used the title “everywhere and nowhere” because there are lots of really useful and productive local implementations of mHealth taking place, but as yet they’re not joined up.  For patients, it means that the technology is arriving in small chunks, often initiated by an individual Doctor or Consultant who’s at the geeky end of the spectrum.  That was confirmed in a review of telehealth projects in the UK in 2008, where Mike Clark concluded that generally they were still pilots of between 5 and 50 users.

For solution providers it means that they need to repeatedly go through the same sales process, convincing another unrelated department of the efficacy of their solution.  As a result, very few of these target more than a thousand users and many are considerably smaller than that, so are still just a drop in the potential ocean of mHealth, albeit very important drops.

We need to be careful about the question of whether any of these initiatives will save the NHS money in the short to medium term.  Many have demonstrably resulted in increased efficiency, as staff have managed to see more patients, have attracted people into the surgery or have reduced wasted time because patients haven’t turned up.  I don’t know of any mHealth application which has resulted in medical staff numbers being reduced, so it is debatable whether the claimed saving are real or accounting subterfuge.

That may not matter.  An important fact about these applications which is often overlooked is that they’re pulling people with diseases, or at risk of disease, into the NHS for immunisations, check ups and earlier diagnosis.  They’re also helping to share patient records, so that treatment is more effective because it’s more joined up.  In other words they’re spearheading a move towards preventative care, with a take-up that is way beyond anything that has been achieved in the past.  It may not save money today, but it is likely to pay dividends in the future.

We need to applaud these pioneers and encourage others to follow suit.  The mobile networks in the UK – Vodafone, O2 and Orange have all announced major investments for mHealth, which are likely to appear during the course of 2011, and which promise to accelerate this deployment.  The reality is that mHealth, even in its simplest forms is already helping to address the future health problems of tens of thousands.  The task for suppliers, GPs and PCTs is to expand that coverage a thousand-fold to bring those benefits to the whole population.